Home Quote
The MJP Insurance Group LLC
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Email
*
example@example.com.... if no email write (None@none.com)
Address of Property
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (If different from Property Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Marital Status
*
Please Select
Single
Married
Widowed
Co-Applicant
*
Please Select
Yes
No
Co- Applicant Name:
Co-Applicant Date of Birth
-
Month
-
Day
Year
Date
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Home Information
Home Insurance Form
*
Please Select
Home (H03)
Manufactured
Renters (H04)
Condo (H06)
Landlord (DP3)
Other
Mortgage on Home
*
Please Select
Yes
No
If Mortgage list Mortgagee
Manufactured Home Make and Serial Number
Manufactured Home Length x Width (Required for Manufactured Home Quote)
Manufactured Home Site Built Additions
Please Select
Yes
No
If site built additions, List Sq. ft.
Responding Fire Department
Date Home was Purchased
*
-
Month
-
Day
Year
Date
Protection Class
*
Please Select
1
2
3
4
5
6
7
8
9
10
I don't know
Primary/Seasonal/Secondary/Vacant
*
Please Select
Primary
Seasonal
Secondary
Vacant
Sq. Feet of Home
*
Home Value (How much Insurance do you want on Home)
*
Please leave out $ sign.
Liability Limits
*
Please Select
$25,000
$100,000
$300,000
$500,000
$750,000
$1,000,000
More
How Many Attached Garages
*
Please Select
1
2
3
More
None
Tenants
Please Select
Yes
No
Builder Grade
*
Please Select
Average
Custom
Luxury
Year Built
*
-
Month
-
Day
Year
Estimate month and day we need correct year.
How Many Bedrooms?
*
Please Select
1
2
3
4
5
6
7
More
How Many Bathrooms?
*
Please Select
1
2
3
4
5
6
7
More
Exterior Walls
*
Please Select
Frame
Block
Log
Other
Primary Heating
*
Please Select
Forced Air (Gas-Electric)
Wood Burning Stove
Fireplace
Other
Secondary Heating
*
Please Select
Wood Burning Stove
Fireplace
Other
None
Heating Update
*
Please Select
Yes
No
If yes.. What year was Heating updated?
-
Month
-
Day
Year
Date
Construction Stories
*
Please Select
1
2
3
More
Foundation
*
Please Select
Slab
Block/Crawl Space
Stilts
Basement
Roof Type
*
Please Select
Metal
Shingle
Other
Roof Update
*
Please Select
Yes
No
If yes.. What year was roof updated?
-
Month
-
Day
Year
Estimate month and day we need correct year.
Electrical Update
*
Please Select
Yes
No
If yes... What year was electrical updated?
-
Month
-
Day
Year
Estimate month and day we need correct year.
Deck(s)
*
Please Select
Yes
No
Square foot of Deck(s)
Out Buildings Sheds/Garages
*
Please Select
Yes
No
Sq. Feet of Sheds/Garages
Pool/Hot Tub
*
Please Select
Pool
Hot Tub
None
Trampoline
*
Please Select
Yes
No
Is Business Run out of House
*
Please Select
Yes
No
Currently Under Construction
*
Please Select
Yes
No
Fire Alarm
*
Please Select
Local
Monitored
None
Pets
*
Please Select
Yes
No
If yes.....Type of Pet/Breed of animal
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Prior Insurance Information
Do you currently have insurance on the Home
*
Please Select
Yes
No
New Build
Recently Cancelled
If no...... How long has property been uninsured
If yes.. Who is the current Insurance Company
Current Expiration Date
-
Month
-
Day
Year
Date
Claims (Last 5 Years)
*
Please Select
Yes
No
Claim Amount Paid Out
Special Requests or Anything else we should know about property
Submit
Should be Empty: